Chief Complaint: Abdominal Pain
History of Present Illness: This is a 7 year old male admitted to Rwinkwavu Hospital Dec 13, 2011 for severe malnutrition (marasmus-type) accompanied with abdominal pain and vomiting for 1 month.
Pertinent Laboratory Values: HIV: Negative
Malaria Smear: Negative
Urinalysis: Negative
Stool Analysis: “Mobile Bacteria”
WBC: 8.25 x 10^9/L
Hgb: 11.2 g/dL
Plt: 680 x 10^9/L
Na: 139 mmol/L
K: 5.7 mmol/L
CL: 104 mmol/L
Ca: 1.16 mmol/L
TCO2: 28
Cr: 84 (normal)
Glucose: 137
SGOT: 19 IU/L
SGPT: 13 IU/L
Amylase: 314 IU/L
Lipase: No reagent
ESR: 70
CRP: Negative
Brief Hospital Course: This patient has been in the hospital for nearly two months now, so I will do my best to summarize their hospital course so far. Per protocol, the child was started on RUTF, as well as amoxicillin (1 week), folic acid, multivitamin, albendazole (3 days), and flagyl (2 weeks). He was also given intermittent pethidine and morphine injections for his abdominal pain, which speaks to its severity. While the child initially gained weight (12kg → 14kg over his first couple weeks), he continued to have intermittent abdominal pain and vomiting. Vital signs remained normal, and he has not had a fever during his entire hospital stay. Aside from a slight elevation of his amylase and some “mobile bacteria” seen on stool microscopy, his labs have been relatively normal (see most recent labs below) without any anemia or leukocytosis. A chest x-ray done on Jan 1, 2012 showed a question of reticular opacities, and an abdominal ultrasound done the same day showed a question of mesenteric lymphadenopathy, and so the patient was started presumptively on anti-TB therapy, with the thought that abdominal TB might be the cause of his pain. The patient continues to have daily severe abdominal pain and vomiting, despite TB therapy for nearly a month.
Specific Clinical Questions: We repeated the abdominal ultrasound today, and found two significant abnormalities. We are posting the images to get some help with the interpretation of the ultrasound findings. The first image is a transverse view of the liver taken in the epigastric region, which seems to show a large liver cyst, perhaps consistent with an amebic abscess (though odd the patient has not had fever). The second image is a longitdudinal view of the kidney taken at the left posterior axillary line. It seems to show a large cyst enveloping and compressing the kidney. Could this also be an amebic abscess? Would a CT abdomen be helpful in making a definitive diagnosis? It would be great to get further input on this challenging case.
